Reassessing the need for long-term oral anticoagulation following successful atrial fibrillation ablation: a systematic review and meta-analysis

The decision to continue or discontinue oral anticoagulation (OAC) after catheter ablation for atrial fibrillation (AF) requires balancing thromboembolic and bleeding risks, and the need for long-term OAC after a successful procedure remains unclear. Thus, we aim to evaluate the safety of discontinuing OAC compared with continuation after apparently successful AF ablation.

PubMed, Embase, Cochrane Central, and Web of Science were searched for randomized controlled trial and cohort studies comparing OAC discontinuation with continuation. Eligible studies required no evidence of AF recurrence before group allocation. A random-effects model with Hartung-Knapp-Sidik-Jonkman adjustment was used to estimate pooled risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI).

Thirteen studies encompassing 249,452 patients were included. No difference was observed between groups for thromboembolic events (RR 0.932; 95% CI 0.624 to 1.393; GRADE: very low quality of evidence), nor when stratifying for patients with CHA2DS2-VASc ≥ 2 (RR 1.289; 95% CI 0.673 to 2.469) or < 2 (RR 0.786; 95% CI 0.353 to 1.751). For major bleeding, discontinuing OAC was associated with a significant reduction in events (RR 0.332; 95% CI 0.167 to 0.659; GRADE: low quality of evidence). Finally, for all-cause mortality, no difference between groups was observed (HR 0.977; 95% CI 0.889 to 1.073; GRADE: very low quality of evidence).

Discontinuing OAC after successful AF ablation may reduce the risk of major bleeding while not increasing the risk of thromboembolism. However, further studies with proper designs are needed to confirm these associations.